Vestibular Lab Testing: Interpreting the Results in the Headache Patient with Dizziness.

PURPOSE OF REVIEW: To provide an overview of vestibular lab testing and to familiarize the reader with common results observed in headache patients with dizziness. RECENT FINDINGS: The latest research indicates variable levels of both peripheral and central vestibular dysfunction in headache populations with dizziness. Mechanisms may include vestibulocerebellar loss of inhibition, central vestibular network misfiring, and peripheral pathology aggravating central hypersensitization. Headache patients are commonly affected by dizziness stemming from various etiologies. Although history is still the gold standard in diagnosis, vestibular lab testing can identify the integrity of vestibular function. Research is emerging and future directions are encouraging.

Valsalva-triggered pseudotumor cerebri syndrome: Case series and pathogenetic implications.

OBJECTIVE: To report the clinical and radiologic features of 3 patients in whom prolonged vigorous coughing/Valsalva triggered the development of pseudotumor cerebri syndrome (PTCS) that persisted even after the coughing attacks had stopped and to discuss how this novel proximate trigger supports a "hydraulic model" of PTCS pathogenesis. METHODS: This was a retrospective case series of 3 patients seen between January 2011 and July 2017 in a tertiary care neuro-ophthalmology clinic. RESULTS: Three female patients (ages 13, 28, and 21 years) were asymptomatic until developing prolonged fits of profuse coughing. Two patients had upper respiratory tract infections, and 1 patient had a prolonged asthma exacerbation. Symptoms typical of PTCS began 2 weeks into the coughing attacks, and patients were examined 1 to 2 weeks after coughing had ceased. One patient was overweight and 2 were obese. All 3 patients had papilledema, and 1 of 3 patients had lateral rectus palsy. Two of 3 patients had visual field defects, and all 3 patients had dural venous sinus stenoses (DVSS) on venous imaging. Lumbar puncture (LP) confirmed elevated opening pressures in 2 of 3 patients and brought immediate and sustained relief of symptoms; LP attempts failed in the third patient because of body habitus (body mass index 68 kg/m2). All patients were given acetazolamide and advised to work on weight loss. At follow-up 3 to 6 months later, all 3 patients had complete remission of their clinical syndromes and resolution of their DVSS on neuroimaging. CONCLUSIONS: In susceptible individuals, prolonged coughing/Valsalva can trigger PTCS in the setting of collapsible (nonfixed) DVSS. This new observation supports a hydraulic model of PTCS pathogenesis.

Refractory Epilepsy: The Role of Positron Emission Tomography.

RATIONALE: Presurgical localization of the epileptogenic focus is critical to successful surgery. Traditionally, localization of the epileptogenic focus depends on seizure semiology, scalp video-electroencephalography (vEEG), magnetic resonance imaging (MRI), neuropsychological assessment, and, when needed, intracranial EEG (iEEG). We aimed to explore the role of positron emission tomography (PET) in the presurgical evaluation of patients with refractory epilepsy. METHODS: A retrospective review was conducted on patients from London Health Sciences Centre (London, Ontario) with refractory epilepsy who underwent PET from September of 2011 to April of 2016. The accuracy of epileptogenic focus localization was compared between different investigative modalities (MRI, vEEG, iEEG, PET), and the outcomes were documented, including seizure freedom after surgical resection, improvement of seizure frequency, guidance for further investigations, and exclusion of patients from further evaluation. Patients who underwent surgery were followed up at 3 months and onward. RESULTS: We identified 62 patients with refractory epilepsy who underwent PET. The mean age was 34 years (range=20-68). A total of 36 had concordant PET and vEEG findings: 6 had surgical resection and either became seizure-free (29.4%) or had improvement in seizure frequency (5.9%) at 3 months; 11 had surgical resection and either became seizure-free (29.4%) or had improvement in seizure frequency (35.3%) at 3 months, but required iEEG for final verification. CONCLUSIONS: PET has an important role in presurgical evaluation of patients with refractory epilepsy. It may allow resection of the epileptogenic focus without the need for iEEG, guiding intracranial electrode placement for further localization of the epileptogenic focus, or exclusion of patients from further evaluation.

New Onset Focal Stabbing Headache Associated With Peripheral Vertigo: A Case Report.

We present a novel case of a focal stabbing headache sharing features of primary stabbing headache that started and resolved with the onset and resolution of a course of self-limiting peripheral vertigo. The association of onset and improvement of the stabbing headaches support the trigeminal and vestibular reciprocal relationships. Vestibular input may be the driving force and a potential target for treatment.

Ramsay Hunt Syndrome Associated with Central Nervous System Involvement in an Adult.

Ramsay Hunt syndrome associated with varicella zoster virus reactivation affecting the central nervous system is rare. We describe a 55-year-old diabetic female who presented with gait ataxia, right peripheral facial palsy, and painful vesicular lesions involving her right ear. Later, she developed dysmetria, fluctuating diplopia, and dysarthria. Varicella zoster virus was detected in the cerebrospinal fluid by polymerase chain reaction. She was diagnosed with Ramsay Hunt syndrome associated with spread to the central nervous system. Her facial palsy completely resolved within 48 hours of treatment with intravenous acyclovir 10 mg/kg every 8 hours. However, cerebellar symptoms did not improve until a tapering course of steroid therapy was initiated.